Purpose of Your Job Position: The primary purpose of your job position is to provide basic nursing care in accordance with our established policies and procedures, and as may be directed by the Charge Nurse, Head Nurse, Nursing Supervisor, Director of Psychiatric Nursing, the Director of Nursing, Program Director or Administrator, to assure that the highest degree of quality resident care is maintained at all times.

General Information: Administratively works under the supervision of a Registered Nurse. Works directly under the clinical supervision of a Registered Nurse, LVN, or Psychiatric Technician in providing patient care to individuals suffering from a mental disorder, in order to ensure a quality treatment program in accordance with the policies set forth by the hospital administration. Under the supervision of Licensed Nursing staff will serve in the capacity of Primary Therapist on a caseload of residents and/or will execute other duties as assigned and in the manner outlined in the Nursing Procedure Manual.

Listed below is an outline of the major duties and responsibilities that you will be required to perform. You are delegated the authority, responsibility, and accountability necessary to carry out your assigned duties. Even though your job description is broad, every effort has been made to make this outline as complete as possible. However, we must emphasize that you may be required to perform other related duties and activities.

MAJOR DUTIES AND RESPONSIBILITIES

BASIC RESPONSIBILITIES:

Performs procedures for basic nursing care and other related services for assigned residents.

SPECIFIC DUTIES:

• Administratively reports to Charge Nurse.

• May function as a Primary Mental Health Aide under the clinical supervision of a Licensed Nurse (R.N., L.V.N. or P.T.)

• Assists physicians and other mental health professionals.

• Performs basic assessments on new admissions that are reviewed and cosigned by an R.N.

• Assists in developing initial treatment plans for residents on admission as assigned.

• Participates in interdisciplinary treatment team meetings as assigned for ongoing treatment planning of residents .

• Participates in or leads unit group activities.

DIRECT CARE RESIDENT FUNCTIONS:

• Will provide direct care to residents as directed under the clinical supervision of licensed nursing staff.

• Will supervise and/or assist the resident with the following as needed:

• Personal hygiene/self-care/grooming

• Shaving/showering/bathing

• Environmental management/sanitation

• Making beds/storing belongings

• Personal laundry/clothing

• Dressing/undressing

• Nourishment and fluid intake

• Elimination needs/use of bathroom

• Provides for resident safety and prevents self-injury, environmental injury, and/or injury from others.

• Observes residents' behaviors and continuously assesses residents' mental status.

• Provides one-to-one supervision of resident activities as assigned.

• Assist in preparing residents for meals. (taking to/from the dining room, supervision in the dining room, etc.)

• Record residents' food intake as directed.

• Feed residents who cannot feed themselves.

• Serve nourishment in accordance with established nursing care procedures.

• Make rounds at least every hour.

• Know where every resident is whim making rounds (check showers, etc.)

• Check and make sure all doors that are to be locked are locked.

• Report any patient leaving the premises, or who has left the premises, to the Charge Nurse immediately.

• Keep written notes of pertinent information; report to nursing person in charge of the unit; and record on residents' records:

• Personal appearance (positive and/or negative)
• Shaving/showering/bathing
• Behavior (describe)
• Activities (if participated or refused)

• Use appropriate techniques in the management of assaultive behavior

• Use restraints and locked seclusion in accordance with our established policies and procedures.

• Report any resident abuse immediately (i.e. harsh/abusive language, unnecessary roughness, etc.)

• Watch for and report any change in room temperature, ventilation, lighting, etc.

• Assure that established smoking regulations are followed by personnel, visitors, residents, and the general public. Report violations to the Charge Nurse immediately.

• Assist in getting residents to and from groups and other activities.

• Assists in getting residents up for meals and medications.

• Assists with room searches as may be necessary.

• Responds to "code green" as per our policy and procedures.

• Provides emergency first aid and/or CPR if needed.

• Takes residents' vital signs as directed and in accordance with our nursing procedures.

• Documents in the IDNs process notes, progress notes, and informative notes per Treatment Plan Manual Guidelines.

• Documents on IDNs Quarterly Summary of resident if assigned by the Treatment Team.

ADMINISTRATIVE FUNCTIONS:

• Ensure that the Nursing Service Procedures Manual is followed while performing nursing care procedures.

• Assist in developing methods for coordinating nursing services with other resident services to ensure the continuity of the resident's total regimen of care.

• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc. as necessary.

• Reviews the reference material (i.e. PDR's, Federal and State Regulations, etc.) maintained at the nurses' station.

• Participate in the development, maintenance, and implementation of the facility's quality assurance program for the Nursing Services Department.

• Periodically review the resident's written treatment plan. Participation in updating the resident's written treatment plan is required.

• Participate in surveys (inspections) made by authorized government agencies.

• Make written and oral reports/recommendations to the Director as necessary/required, concerning the operation of the Nursing Services Department.

• Periodically review the department's policies, procedures manuals, job descriptions, etc. Make recommendations for revisions.

• Meet with other nursing staff, as well as support personnel, in planning the department's services, programs, and activities.

• Interpret the department's policies and procedures to personnel, residents, visitors, and government agencies as required.

• Admit, transfer, and discharge residents as required.

• Complete accident/incident reports as necessary.

COMMITTEE FUNCTIONS:

• Attend various committee meetings of the facility (i.e. Infection Control, Policy Advisory, Pharmaceutical, Quality Assurance, etc.) as required.

• Assist in preparing written and/or oral reports of the nursing service programs and activities to submit to such committee(s) as directed.

• Participate in developing the agenda for Care Plan Committee meetings as necessary.

• Participate in regularly scheduled reviews of the Treatment Plans.

• Attend and participate in the Utilization Review Committee functions as required or as may be necessary.

• Implement recommendations from established committes as instructed by the Department Director.

PERSONNEL FUNCTIONS:

• Develop and maintain good working rapport with inter-department personnel, as well as other departments within the facility to assure that nursing services and activities can be adequately maintained to meet the needs of the residents.

• Assure that department personnel, residents, and visitors follow the department's established policies and procedures at all times, including dress codes.

• Create and maintain an atmosphere of warmth, personal interest, and positive emphasis, as well as a calm environment throughout the unit and shift.

• Meet with your Charge Nurse on a regularly scheduled basis to assist in identifying and correcting problem areas, and/or the improvement of services.

NURSING CARE FUNCTIONS:

• Inform nursing service personnel of new admissions, their expected time of arrival, room assignment, etc.

• Ensure that rooms are ready for new admissions.

• Greet newly admitted residents upon admission. Escort to room as necessary.

• Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided and that they reflect the resident's response to care. Make rounds with physicians as necessary.

• Encourage attending physicians to record and sign progress notes, physician orders, etc. on a timely basis and in accordance with current regulations.

• Make daily resident visits to observe and evaluate the resident's physical and emotional status.

• Report problem areas to the Charge Nurse. Assist in developing and implementing corrective action.

• Keep the Charge Nurse informed of the status of residents and other related matters through written/oral reports.

• Meet with residents, and/or family members, as necessary. Report problem areas to the Charge Nurse.

• Assist in arranging transportation for discharged residents as necessary.

• Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner.

• Consult with the resident's Treatment Team in planning resident care, treatment, rehabilitation, etc. as necessary.

• Notify the resident's physician when there is a change in the resident's condition.

• Work with the facility's consultants and implement those changes authorized by the Director.

• Obtain sputum, urine and other specimens as ordered.

• Take TPR's, blood, and discharge residents as necessary.

• Assist the Staff Nurse in monitoring seriously ill residents.

STAFF DEVELOPMENT:

• Participate in in-service training classes that provide instructions on "how to do the job", and ensure a well-educated nursing services department.

• Participate in the orientation of new employees to your shift, its routing policies, and procedures, and to his/her position duties.

• Attend and participate in continuing education programs designed to keep you abreast of changes in your progression, as well as to maintain your license on a current status.

SAFETY AND SANITATION:

• Assist the Safety Officer in developing safety standards for the Nursing Services Department as necessary.

• Follow established safety regulations in the use of equipment and supplies.

• Ensure that nursing service work areas (i.e. nurses stations, medicine preparation rooms, etc.) are maintained in a clean and sanitary manner.

• Ensure that all resident care rooms, treatment areas, etc. are maintained in a clean, safe, and sanitary manner.

• Follow established department policies and procedures.

• Participate in all fire, safety, and disaster preparedness drills in a safe and professional manner.

• Participate in the development, implementation, and maintenance of the infection control program for monitoring communicable and/or Infectious diseases among the residents and personnel.

• Follow established infection control procedures when isolation precautions become necessary.

• Participate in the development, implementation, and maintenance of the procedures for reporting hazardous conditions or equipment.

• Follow established handwashing techniques in the administering of nursing care procedures.

EQUIPMENT AND SUPPLY FUNCTIONS:

• Participate in the development and implementation of the procedures for the safe operation of all nursing service equipment.

• Operate nursing services equipment in a safe manner and ensure that supplies are used in an efficient manner to avoid waste.

CARE PLAN AND ASSESSMENT FUNCTIONS:

• Participate in the development of a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care.

• Insofar as practical, encourage the resident to participate in the development and review of his/her plan of care.

• Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs.

• Review nurses' notes to determine if the care plan is being followed.

RESIDENT'S RIGHTS FUNCTIONS:

• Maintain the confidentiality of all resident care information.

• Assure that all residents are treated fairly, and with kindness, dignity, and respect.

• Ensure that all nursing care is provided in privacy and that nursing service personnel knock before entering the resident's room.

• Ensure that all nursing service personnel are knowledgeable of the resident's rights, and responsibilities.

• Report any/all resident complaints or grievances to the Charge Nurse immediately.

MISCELLANEOUS:

• Assist the Infection Control Coordinator in identifying, evaluating, and classifying Category I and II tasks.

• Provide information to the Quality Assurance and Assessment committee as requested.

WORKING CONDITIONS

• Works in well-lighted and ventilated office area(s), as well as throughout the nursing service areas.

• Sits, stands, bends, lifts, and moves intermittently during working hours.

• Is subject to frequent interruptions.

• Is involved with residents, personnel, visitors, government agencies/personnel, etc. under all conditions and circumstances.

• Is subject to hostile and emotionally upset residents, family members, personnel, and visitors.

• Communicates with medical staff, nursing personnel, and other staff.

• Is willing to work beyond normal working hours, on weekends, and holidays when necessary.

• Is involved in community/civic health matters/ projects as appropriate.

• Attends and participates in continuing educational programs designed to keep you abreast of changes to your profession.

• Is subject to falls, burns from equipment, odors, etc. throughout the workday.

• Is subject to exposure to infectious waste, diseases, conditions, etc. including exposure to the AIDS and Hepatitis 8 viruses.

• Maintains a liaison with the residents, their families, support departments, etc. to adequately plan for the resident's needs.

• Subject to hostile and assaultive behaviors of mental health residents.

QUALIFICATIONS

Current certified nurses assistant certificate with one year paid experience in Mental Health or related health care setting.

Experience: One to two years of experience in a mental health setting is preferred. Training in P.A.R.T. and C.P.R. certification.

SPECIFIC REQUIREMENTS:

• Certified as a Nursing Assistant or eligible for Certificate per requirements.

• Must possess a sincere desire to work with the mentally ill.

• Must be able to read, write and speak English in an understandable manner.

• Must possess the ability to make independent decisions, when circumstances warrant such action.

• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.

• Be a minimum of 18 years of age.

• Knowledgeable of nursing and medical practices and procedures.

• Ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies, procedures, etc. of the nursing service department.

• Maintain the care and use of supplies, equipment, etc., and maintain the appearance of nursing areas, with regular inspection of nursing units for sanitation, order, safety, and proper performance of assigned duties.

• Must have patience, tact, cheerful disposition, and enthusiasm, as well as be willing to handle patients based on whatever maturity level at which they are currently functioning.

• Possess the ability to seek out new methods and principles and be willing to incorporate them into existing nursing practices.